Inhalational induction of general anaesthesia for elective caesarean: ethical acceptability in treatment-resistant needle phobia?

We describe the anaesthetic management of a parturient who, due to a severe needle phobia, requested an inhalational induction of general anaesthesia for an elective caesarean section. If general anaesthesia is indicated, conventional practice in the UK is to perform a rapid sequence induction via an intravenous route of drug administration to allow rapid intubation of the trachea. This is because obstetric patients are considered to have a 'full stomach' due to the effects of pregnancy and labour on gastric emptying, and a higher risk of aspiration with consequent maternal and fetal adverse outcomes. Despite a thorough consent process highlighting these significant risks, the patient insisted on an inhalational induction of anaesthesia. We present the case and discuss the ethical dilemma (relating to patient care) in situations in which decisions made by patients deviate from medical recommendations.

The politics of female pain: women's citizenship, twilight sleep and the early birth control movement.

The medical intervention of 'twilight sleep', or the use of a scopolamine-morphine mixture to anaesthetise labouring women, caused a furore among doctors and early 20th-century feminists. Suffragists and women's rights advocates led the Twilight Sleep Association in a quest to encourage doctors and their female patients to widely embrace the practice. Activists felt the method revolutionised the notoriously dangerous and painful childbirth process for women, touting its benefits as the key to allowing women to control their birth experience at a time when the maternal mortality rate remained high despite medical advances in obstetrics. Yet many physicians attacked the practice as dangerous for patients and their babies and antithetical to the expectations for proper womanhood and motherly duty. Historians of women's health have rightly cited Twilight Sleep as the beginning of the medicalisation and depersonalisation of the childbirth process in the 20th century. This article instead repositions the feminist political arguments for the method as an important precursor for the rhetoric of the early birth control movement, led by Mary Ware Dennett (a former leader in the Twilight Sleep Association) and Margaret Sanger. Both Twilight Sleep and the birth control movement represent a distinct moment in the early 20th century wherein pain was deeply connected to politics and the rhetoric of equal rights. The two reformers emphasised in their publications and appeals to the public the vast social significance of reproductive pain-both physical and psychological. They contended that women's lack of control over both pregnancy and birth represented the greatest hindrance to women's fulfilment of their political rights and a danger to the healthy development of larger society. In their arguments for legal contraception, Dennett and Sanger placed women's pain front and centre as the primary reason for changing a law that hindered women's full participation in the public order.

Anestesia obstétrica. Un reto en nuestras manos / No disponible

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Informed consent for labor epidurals: a survey of Society for Obstetric Anesthesia and Perinatology anesthesiologists from the United States.

BACKGROUND: Ethicists agree that informed consent is a process rather than just simply the signing of a form. It should provide the patient with needed information and understanding to authorize a procedure. Essential elements of informed consent for women requesting labor epidurals include a description of the procedure, the risks and benefits, and alternative treatments for analgesia including the associated risks and benefits. The purpose of this pilot study was to determine practices and opinions of obstetric anesthesiologists regarding informed consent for parturients. METHODS: Questionnaires were sent to 885 anesthesiologists who were members of the Society of Obstetric Anesthesia and Perinatology based in United States institutions in 2002. RESULTS: Of the 885 questionnaires sent, 448 (51%) were returned with 47% from academic and 47% from private practice institutions. Forty-six percent worked as part of an obstetric anesthesia team; 51% worked in centers where there were >3000 deliveries/year. Sixty-eight percent suggested that "parturients in active labor are able to give informed consent for labor epidural analgesia." Thirteen percent recommend antenatal anesthesia consults for parturients inquiring about labor epidurals and 41% participated in childbirth classes. Responses did not differ significantly between physicians in academic vs. private practice. More obstetric team practices than non-team practices participated in childbirth education (54% vs. 30%, P < 0.0001). CONCLUSION: Despite the painful, stressful circumstances confronted by parturients, many respondents (76% in academic, 64% in private practice) thought that women in active labor are able to give informed consent.

Ethical aspects of informed consent in obstetric anesthesia--new challenges and solutions.

Informed consent is a cornerstone and routine component of the ethical practice of modern medicine. Its full theoretical application to specific clinical situations, however, presents a number of ethical dilemmas for health care providers. Obstetric anesthesia, in particular, presents many unique challenges to the process of informed consent. In this review, the ethical background to the doctrine of informed consent within the context of "principlism" is explored and critiqued. The application of principlism to actual clinical situations, the limitations of principlism in the peculiarities of the patient-physician encounter, as well as possible alternative models of ethical discourse is discussed. The process of informed consent can be broken down into seven elements: Threshold elements or preconditions, which include 1) decision-making capacity or competency of the patient, 2) freedom or voluntariness in decision-making, including absence of over-riding legal or state interests; informational elements, including 3) adequate disclosure of material information, 4) recommendation, and 5) an understanding of the above; consent elements, which include 6) decision by the patient in favor of a plan and 7) authorization of that plan. Each of these elements is discussed in turn, and their implications, especially for the anesthesiologist and the obstetric patient, are addressed.